Report points to failings at VA hospital

A mentally ill veteran with COVID-19 died last year at the Michael E. DeBakey VA Medical Center after the hospital violated its policies and failed to properly manage the patient, according to a report published Wednesday by the Department of Veterans Affairs Office of Inspector General.

The patient was only identified as a person in their late 60s with a history of congestive heart failure, chronic schizophrenia and a recent diagnosis of prostate cancer. The patient also had cognitive and communication impairments, according to the report.

Among the reported violations, hospital staff initially failed to take the patient’s temperature, did not isolate them when they showed COVID symptoms and allowed the patient to move freely throughout the hospital grounds. At one point, the patient went missing before they were found offsite four days later, the report said. The patient died the day after returning to the hospital.

“The Michael E. DeBakey VA Medical Center is saddened and heartbroken over the loss of this Veteran and extends its deepest condolences to the family,” according to a statement from the hospital. “While this isolated incident that occurred during the height of pandemic last year does not represent the quality health care southeast Texas Veterans have come to expect from our facilities, it has prompted a number of improvements that will strengthen our continuity of care and prevent similar issues from happening in the future.”

The statement goes on to say that the hospital has “greatly refined and improved our COVID screening and testing processes” and implemented each of the report’s nine recommendations, including ensuring that staff manage suspected COVID patients according to local and regional guidelines.

According to OIG’s inspection, the patient went to the hospital in mid-summer 2020 with low back pain. Staff did not take the patient’s temperature upon entry, but a later temperature check showed a fever of 102.8 degrees, the report said. The patient showed symptoms such as fast breathing, low oxygenation and a pain level of 7 out of 10. A physician acknowledged that they did not further evaluate the patient.

Another doctor ordered a COVID test, and a staff member took the patient by wheelchair to a drivethrough testing area. After the test, the patient was escorted to a parking lot near the emergency department. Security video caught the patient alone at a nearby bus stop for about an hour. A bus pulled up, blocked the camera’s view and the patient was no longer visible on the video, the report said.

The patient went missing. Family arrived at the hospital on two different days searching for them, the report said. The patient was not seen until four days later, when they went into cardiac arrest at a bus stop. The patient was taken back to the hospital and tested positive for COVID. The results of the initial COVID test came also back positive.

The patient died the following day.